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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001484
Report Date: 07/06/2022
Date Signed: 07/06/2022 09:34:35 AM


Document Has Been Signed on 07/06/2022 09:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUMMER'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
347001484
ADMINISTRATOR:PAUL LOMENDEHEFACILITY TYPE:
740
ADDRESS:130 MANITOU STREETTELEPHONE:
(916) 567-0759
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:5CENSUS: 5DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lucas Manurung TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 07/06/2022. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The LPA toured the facility with Lucas Manurung on 06/07/2022 at 9:00 AM.

A LIC 808 Covid-19 Mitigation Plan and an Infection Control Plan have been submitted to the Department, The facility has a main Covid-19 Screening entry point, and has a designated area for visit. The facility has a 30 day supply of PPE. The facility has Covid-19 postings throughout the facility. Additionally, the facility conducts disinfecting cleaning and common furniture is spaced 6 feet a part.

The facility water temperature measured at 110 degrees, and the facility temperature measured at 76 degrees. The facility has an adequate food supply and has emergency food and water. All toxins and cleaning supplies are locked, and the facility is sanitary. The facility smoke and carbon detectors are in good repair. The fire extinguisher is in good repair. The exterior of the home is clear of debris. The exterior emergency exit door is good repair.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


Exit interview was held, and a copy of this was report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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